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The lower premiums for Medica plans and the introduction of Bright’s plans could result in shifting prices for the benchmark plan and corresponding changes in premium subsidy amounts for some enrollees — although consumers may or may not notice a change in their net premiums, even with fluctuations in the subsidy amounts.

As an example, consider a 50-year-old in Lincoln who earns $30,000/year. In 2019, he was eligible for a premium subsidy of $840/month, and had access to seven plans with no premium at all after the subsidy was applied. In 2020, his subsidy amount (assuming he’s still 50 and earning $30,000) drops to $745. But because of the influx of new plans and lower-cost options from Medica, he’ll have access to even more free plans (nine of them) after the subsidy is applied, despite the fact that the subsidy amount is smaller.

For perspective, average unsubsidized premiums in Nebraska’s exchange are much higher than the national average, at $866/month in 2019, versus $612/month across all states that use HealthCare.gov. In Nebraska, more than 93 percent of exchange enrollees receive premium subsidies, but the lower premiums and additional competition will be a welcome relief for enrollees who aren’t subsidy-eligible.

Rate changes in prior years

For perspective, here’s a summary of how rates have changed in Nebraska’s individual market since ACA-compliant plans became available in 2014:

2015: The Nebraska Department of Insurance released a sampling of 2015 rates in September 2014. They illustrated 15 different scenarios, with varying household sizes, ages, and geographic locations across the state. For each carrier, they showed the rate change for each scenario, along with an average for all 15 scenarios from each carrier.Across the four carriers that were originally slated to sell plans for 2015 (including CoOportunity), the unweighted average for the 15 sample scenarios was a 10.7 percent increase in premiums. But one carrier — Coventry — had an average rate decrease of 3.4 percent. And while Assurant’s average rate hike across the sample scenarios was 16 percent, their prices in 2014 (off-exchange) were lower than those offered by the exchange plans — they gained market share in 2014 even though they were only available off-exchange (Assurant ended up leaving the market, nationwide, at the end of 2015.An analysis conducted by the Commonwealth Fund and published in December 2014 found an average rate increase of 10 percent for a 40 year-old non-smoker in the Nebraska exchange, when looking at all plans and metal levels. But for silver plans, the rate increase was an average of just 4 percent, and it’s likely that the rate increase became smaller once CoOportunity’s plans were no longer for sale, since the CO-OP had raised its rates considerably for 2015.

2016: In the fall of 2015, the Nebraska Department of Insurance published final approved rates for 2016:

Coventry: 21.89 percent average rate increase (but actual rates are still lower than BCBS in every sample scenario).

UnitedHealthcare of the Midlands: New to the exchange, but the approved rates for 2016 were lower than BCBS and Coventry for every sample scenario (note that United only participated in the exchange in 2016; they did not offer plans for 2017).

Medica: New to the exchange for 2016. Approved rates for 2016 were lower than BCBS and Coventry in some scenarios, and higher in others.

2017: For the two carriers offering coverage in the Nebraska exchange, average rate increases for 2017 were as follows:

2018: Aetna left the market. Medica increased their average rates by 31 percent. Medica’s rate filing noted that while their plans would be available on and off-exchange for 2018, they were not actively marketing off-exchange plans. Medica offered their “Medica Insure” plan in all 93 counties in Nebraska for 2018. They also offered their “Medica Insure Gold” in 70 counties, and “Medica with CHI Health” in the remaining 23 counties.Medica proposed a 31 percent average rate increase (as of their revised rate filing dated August 15, 2017, which was based on the assumption that cost-sharing reduction (CSR) funding would not continue in 2018). The additional cost to cover CSR was added to silver plans. This turned out to be a prescient decision, as the Trump Administration announced in October 2017 that CSR funding would end immediately.Medica had previously proposed a 16.9 percent average rate increase, based on the assumption that CSR funding would continue. But with no allocation of funding from Congress, and no assurance from the Trump Administration that funding would actually continue, revised rates were filed in August. Medica initially added a 14.5 percent load to silver plans, bringing the total overall average rate increase to 28.3 percent (as of August 4). But they submitted an additional revised filing on August 15, which also incorporated updated claims experience through the end of July. The result of that additional information, plus the 14.5 percent load on silver plans to cover the cost of CSR, brought Medica’s overall proposed average rate increase to 31 percent.

2019: Medica was once again the only insurer in Nebraska’s exchange (indeed, in their entire individual market, including on- and off-exchange plans). Overall, the average rate increase across all of Medica’s plans was 2.2 percent for 2019. This was a much smaller average rate change than prior years, but that’s due in part to the fact that Medica switched from a PPO to an EPO for 2019. It’s also indicative of a more stable insurance market than the state has had in the past few years, and is testament to the fact that the sharp rate increases in 2017 and 2018 appear to have “right-sized” premiums in the state, getting them to where they need to be in order to cover the cost of claims.

Participation in Nebraska’s exchange peaked with four insurers in 2016, but had dropped to just one by 2018. For 2020 there are two insurers offering plans

In 2014, the first year that the ACA-created exchanges were operational, Nebraska’s exchange had three insurers offering plans: Aetna, CoOpportunity (an Iowa-based ACA-created CO-OP), and Blue Cross Blue Shield of Nebraska.

Time (Assurant) joined the exchange for 2015, but CoOpportunity stopped selling plans in December 2014 and was subsequently liquidated; remaining members had to transition to new plans by March 2015. So for 2015, Nebraska’s exchange had plans from Time, Aetna, and Blue Cross Blue Shield of Nebraska.

But Assurant announced in June 2015 that they would exit the individual market nationwide, and their plans were no longer available as of 2016. But two new carriers joined the Nebraska exchange for 2016: UnitedHealthcare of the Midlands, and Medica. So for 2016, there were four insurers offering plans in Nebraska’s exchange: Aetna, Blue Cross Blue Shield of Nebraska, UnitedHealthcare, and Medica.

But UnitedHealthcare announced fairly early in 2016 that they would exit the exchanges in most states — including Nebraska — at the end of 2016. United only joined the Nebraska exchange for 2016 – they weren’t available in the exchange in 2014 and 2015. But their rates were competitive in Nebraska. They offered plans state-wide, and in 65 of the state’s 93 counties, United offered at least one of the two least-expensive silver plans in the exchange.

At that point, it looked like three insurers would participate in Nebraska’s exchange in 2017, and the Nebraska Department of Insurance confirmed by phone in August 2016 that Aetna, Blue Cross Blue Shield of Nebraska, and Medica all planned to offer coverage in the state’s exchange for 2017.

Nebraska Insurance Director Bruce Ramge noted, however, that nothing was final until the carriers signed their agreements with HHS in late September 2016, and said “hopefully we won’t see any other dropouts.” But in late September, Blue Cross Blue Shield of Nebraska announced that they would not offer plans in the exchange in 2017 after all, due to mounting losses. They noted that they had lost $140 million on exchange plans since 2014, and viewed continued participation in the exchange as unsustainable. Blue Cross Blue Shield of Nebraska continued to sell two plans — bronze and catastrophic — outside the exchange for 2017 (in June 2017, BCBSN announced that they would entirely exit the ACA-compliant individual market at the end of 2017. They noted that in order to have continued to offer off-exchange ACA-compliant plans in 2018, they would have had to increase premiums by 50 percent, which would have likely resulted in healthy people dropping coverage while sick people remained on the plans, further increasing overall losses).

So for 2017, Aetna and Medica offered plans in the Nebraska exchange. But Aetna announced in May 2017 that they would not offer on- or off-exchange plans in Nebraska in 2018. In February 2017, Aetna’s CEO, Mark Bertolini, had said that the ACA exchanges were in a “death spiral.” Aetna only offered plans in four state exchanges in 2017, including Nebraska. Bertolini also said that Aetna was the only insurer in the Nebraska exchange in 2017, but Medica also offered plans, and grew their membership significantly in the state in 2017.

Medica offers plans statewide in Nebraska, and has opened an office in Omaha. Their 2017 enrollment in Nebraska increased five-fold over their 2016 enrollment. In 2016, there were 6,276 Medica members in Nebraska. By February 2017, more than 35,500 Nebraska residents had made their initial premium payments for 2017 Medica plans (mostly through the exchange, but that total included off-exchange enrollments as well). Enrollment in the individual market tends to peak early in the year, but Medica’s rate filing later in 2017 indicated that they had 35,269 members.

Medica indicated in February 2017 that they were committed to remaining in Nebraska’s individual market, regardless of the future of the ACA and HealthCare.gov. But there was considerable uncertainty among insurers in the spring of 2017, as the Trump Administration waffled on whether or not they would continue to pay cost-sharing reductions to insurers, and on how strongly the ACA’s individual mandate would be enforced going forward.

Ultimately, Medica did remain in the exchange, statewide. And their membership grew significantly in 2018, as they were the only insurer offering plans in the exchange. In addition, anyone with 2018 off-exchange ACA-compliant individual market coverage in Nebraska also had Medica coverage, as the other insurers had left the market (the bulk of Medica’s membership is on-exchange, however, as the insurer is not actively marketing off-exchange plans).

Medica is once again the only insurer offering plans in the Nebraska exchange in 2019. And as described below, Medica has also partnered with the Nebraska Farm Bureau to offer association health plan coverage to farmers in Nebraska for 2019.

2019 enrollment down less than half a percent, after growing more than 4 percent in 2018

87,416 people enrolled in 2019 coverage through the Nebraska exchange during open enrollment, which ended December 15, 2018. That was less than 1 percent lower than the 88,213 people who enrolled in coverage during the previous open enrollment (for 2018 plans). And enrollment in Nebraska’s exchange grew from 2017 to 2018 (going from 84,371 enrollees to 88,213 enrollees). For states that rely on HealthCare.gov, this was rare, as most of those states saw enrollment decrease by an average of 5 percent. Of the 34 states with fully federally-run exchanges, only five had higher enrollment in 2018 than they’d had in 2017.

Across all states that use HealthCare.gov, there was another average enrollment drop of about 5 percent in 2019, due to a variety of factors: The individual mandate penalty no longer applies after the end of 2018. The Trump Administration relaxed the rules for short-term health plans and association health plans, making them a viable alternative (for healthy people) to ACA-compliant coverage. And as was the case the year before, the Trump Administration again slashed funding for outreach and enrollment assistance. But enrollment in Nebraska’s exchange in 2019 is only slightly lower than it was in 2016.

For perspective, here’s a look at individual market QHP (private plans) enrollment numbers in Nebraska over the years:

The SERFF filing number for the 2020 plan is MEDI-132097655, and it contains information about the transition from the association health plan (AHP) that Medica offered in 2019 in partnership with Farm Bureau. A federal judge overturned the Trump administration’s AHP rules in 2019, and although the ruling has been appealed, sole proprietors without employees cannot enroll in AHPs until if and when the Trump administration’s rules are restored. So for 2020, Medica and Farm Bureau have switched to a short-term health plan instead.

But this short-term plan is different from most short-term plans on the market. Although it does have a gender rating component, it is not medically underwritten for individual applicants, and the coverage is similar to what Medica offers in the ACA-compliant individual market. But because enrollees have to be Farm Bureau members who are actively engaged in agriculture, overall health of the risk pool can be expected to be better than the general population (enrollees need to be healthy enough to work and be involved in agriculture). Nebraska Farm Bureau has said that the plans are about 25 percent less expensive than ACA-compliant plans for 2020.

Members of the 2019 AHP that was offered by Farm Bureau/Medica can transition to the short-term plan for 2020. Premiums are an average of 4.8 percent lower than they were on the 2019 AHP, and while deductibles and out-of-pocket costs are a little higher on the 2020 plan, copays for office visits and prescription drugs are a little lower. Medica’s filing noted that they expect about 1,000 members to be enrolled in the plan for 2020.

Background on alternative coverage arrangements for Nebraska farmers

In 2019, association health plan coverage was available to farmers in Nebraska from Farm Bureau/Medica as well as Land o’ Lakes. This stemmed from new federal rules that the Trump administration issued in 2018 for association health plans, making it easier for self-employed individuals and small groups to join together and obtain health insurance regulated under the ACA’s large group rules. This was still ACA-compliant coverage, but the rules are more lenient for large groups than they are for individual and small group plans (large group plans don’t have to cover the essential health benefits, for example, and aren’t subject to the ACA’s risk adjustment program).

In September 2018, the Nebraska Farm Bureau announced a partnership with Medica to offer an association health plan to Farm Bureau members in the state, at premiums roughly 25 percent below the premiums for ACA-compliant individual market coverage without any subsidies (people who get subsidies pay far less in premiums, but the Farm Bureau plan was marketed to people who don’t get subsidies). The coverage was robust however, and did appear to include all of the ACA’s essential health benefits. There was an open enrollment period from October 1 to December 12, 2018, during which people who were already Farm Bureau members as of July 2018 were allowed to sign up for coverage under the association health plan, and 700 Nebraska residents enrolled in Farm Bureau coverage for 2019. Enrollment was limited to existing Farm Bureau members in an effort to limit adverse selection; they didn’t want lots of people with significant medical needs to join Farm Bureau solely to get health insurance and then enroll in the plan.

Land O’Lakes also began offering an association health plan for 2019 to farmers in Nebraska who were actively engaged in business with one of 14 participating CO-OPs. The open enrollment period for Land O’Lakes association health plan coverage began October 29, 2018, and was initially slated to end December 21. But it was extended until December 31 due to high demand and a late harvest that made it challenging for farmers to enroll in coverage during the original enrollment period.

In March 2019, a federal judge struck down the Trump Administration’s AHP rules. The new AHP rules were supposed to take effect for new self-insured AHPs as of April 1, 2019, but had already taken effect in 2018 for fully-insured AHPs. The Nebraska Farm Bureau confirmed by phone in mid-April 2019 that their fully-insured AHP coverage continued to be available, and nothing had changed for them. Gravie, which administers the Land O’Lakes AHP, also confirmed that nothing had changed about their plan availability as a result of the court ruling; eligible CO-OP members who experienced a qualifying event could still enroll in the Land O’Lakes association health plan (enrollment in these plans was otherwise limited to an annual open enrollment period). But in May, the Department of Labor issued new guidance noting that while existing AHPs would be able to finish their current plan year/contract, AHPs would not be able to continue to enroll new members (the Trump administration appealed the court’s ruling).

It should be noted that the association health plan approach that was used for farmers in Nebraska in 2019, and the short-term Medica plan that’s being offered to Nebraska Farm Bureau members in 2020, are not the same thing that Farm Bureau is offering in Iowa and Tennessee.

In Iowa and Tennessee, Farm Bureau plans are medically underwritten, so they’re only available for purchase by people who are fairly healthy. Under the Trump Administration’s rules for association health plans, the plans cannot use medical underwriting to determine eligibility or premiums, but the Iowa and Tennessee Farm Bureau plans are not association health plans. Instead, they’re similar to the pre-ACA individual market: Coverage is available year-round, anyone can join the Farm Bureau (even if they’re not involved in agriculture) and apply for coverage, but eligibility for coverage is based on the applicant’s medical history.

In Nebraska, however, residents could only enroll in Farm Bureau or Land O’Lakes AHP coverage if they were involved in agriculture, enrollment was limited to an annual open enrollment window, and an enrollee’s health status was not taken into consideration. For 2020, Land O’Lakes is no longer offering coverage in Nebraska, and although Farm Bureau is, the specifics still differ significantly from the Iowa/Tennessee approach, in that members can only enroll during open enrollment and must be actively engaged in agriculture, but medical underwriting is not being used to determine eligibility for coverage.

If you get premium subsidies, you might have seen a rate reduction in 2018, and even more of a rate decrease for 2019

Because the cost of CSR has been added to silver plan premiums starting in 2018, premium subsidies are much larger than they would otherwise have been. Consider a family of four, living in North Platte (parents are 45, and the kids are 15 and 13, and we’ll keep them the same each for each year in order to compare apples to apples and avoid the inevitable premium increases that happen just because we each get older every year).

If they earned $97,000 in 2018, they qualified for a premium subsidy of $2,130 per month. After that subsidy was applied, they could get a bronze plan for as little as $141/month (if they wanted a silver plan in 2018, it would have cost $773/month, and if they wanted a gold plan, it was $1,099/month, after the subsidy was applied).

For 2019, Medica adjusted their pricing to result in even better bargains for people who get premium subsidies (an insurer can do this if they’re the only one offering plans in a particular area, since they know they’ll have the benchmark plan, and will thus know exactly how much all of their plans differ in price from the benchmark plan’s price). If our hypothetical family in North Platte earned $97,000 in 2019, they qualified for a premium subsidy of $2,389/month. They could select from two bronze plans that were entirely free after the subsidy was applied. Or they could get a gold plan for $303/month. There was only one silver plan available, so it was the benchmark and it would have been $778/month after the subsidy (note that this is very similar to the cost of the silver plan in 2018; the benchmark rate stays fairly constant from one year to the next, after subsidies are applied, for people with fairly consistent income).

But in 2017, a family in that same situation would have qualified for a premium subsidy of just $1,322 per month (substantially lower than the 2018 and 2019 subsidy amounts), and the cheapest bronze plan available to them would have been $479/month in after-subsidy premiums (a silver plan would have been at least $748/month — similar to 2018 and 2019 costs, because again, premium subsidies are designed to keep the cost of silver plans fairly consistent from one year to the next — and there were simply no gold plans available in their area (69101 zip code) for 2017).

To be clear, premiums for people who don’t qualify for premium subsidies are substantial. If the family in North Platte earned more than $98,400 in 2018, their least-expensive option was a bronze plan that cost $2,282/month in premiums. [Keep in mind that the $98,400 amount was after any contributions to employer-sponsored or self-employment retirement plans, and after any contributions to an HSA. The least-expensive bronze plan was HSA qualified and would have allowed this family to set aside up to $6,900 in an HSA in 2018, lowering their adjusted gross income by that amount.] For 2019, if that family earned more than $100,400 (again, after deductions that will lower their ACA-specific MAGI), their lowest-cost option was $2,314/month.

But there are a few points that need to be made about Sasse’s tweet:

The median income for farm families in the US was under $78,000 in 2017 (the income comes from their non-farm sources, since median net farm-related income is slightly negative).

An income of $78,000 will result in premium subsidies for families with three or more members. As noted above, the subsidies became much more substantial starting in 2018. If our family in North Platte was earning $78,000 in 2018, their premium subsidy would have been $2,282 per month, and they could have obtained a bronze plan for free after the subsidy was applied. With a $78,000 income for 2019, they would qualify for a subsidy of $2,545/month and would have access to three free bronze plans and a gold plan that costs just $145/month for the whole family.

If the family is eligible for employer-sponsored coverage due to one or both spouses having another job in addition to the farm, they can use that coverage instead of buying individual market coverage. But they may be in a situation where it’s only affordable for the employee, and not for the whole family. That’s known as the family glitch. Former Minnesota Senator Al Franken introduced legislation in 2014 to fix the family glitch, but it did not have enough support to pass.

HHS noted in 2016 that premiums are about 7 percent lower, on average, in states that have expanded Medicaid versus states that have not. Nebraska has not expanded Medicaid, although the state is moving forward with a plan to expand coverage by the fall of 2020, after Nebraska voters approved a Medicaid expansion ballot initiative in the 2018 election. But since Medicaid has not yet been expanded in the state, hospitals face more uncompensated care costs in Nebraska than they would if Medicaid had already been expanded. The multi-year delay in expanding Medicaid in Nebraska also means that the private plans in the exchange are covering people with incomes as low as the poverty level. If the state had expanded Medicaid, the private plans in the exchange would be covering people with incomes of 139 percent of the poverty level and above, since people with income below that level would be eligible for Medicaid instead. Lower incomes correlate with poorer health, so the overall risk pool for private plans in Nebraska would be expected to be healthier (and thus, lower-cost) if Medicaid were expanded. Sasse is a federal lawmaker, so the decision to not expand Medicaid was not his (that rests with governors and state lawmakers). But Sasse has been openly critical of the coverage gains made in other states as a result of Medicaid expansion, perhaps not understanding that it’s a key component of keeping private plan premiums in check?

As noted above, the average premium increase in Nebraska was slated to be 16.9 percent for 2018, and that would have been the case if federal lawmakers — including Sasse — had allocated CSR funding. But they didn’t, and the result was an average rate increase of 31 percent in Nebraska. Granted, that’s also what has resulted in such oversize premium subsidies in 2018 and 2019, and unsubsidized consumers can avoid the CSR load on premiums by selecting a non-silver plan. But it’s somewhat ironic that the primary factor that drove rate increases for 2018 is something that federal lawmakers could have addressed at any time during early-mid 2017. The rate increases that resulted from the lack of CSR funding were not a surprise — insurers made it very clear in their rate filings that the impact on rates would be substantial if CSR funding were not allocated, but Republican lawmakers preferred to spend much of 2017 focusing on ACA repeal efforts, rather than taking action to stabilize the individual health insurance market.

Nebraska resisted Healthcare.gov re-enrollment, but it proceeded as planned

For 2015 and 2016, Healthcare.gov did not have a means of automatically selecting a new plan for enrollees if their health insurer was exiting the exchange altogether. In those instances, enrollees had to either select a new plan themselves during open enrollment, or become uninsured as of January 1.

But in the 2017 Benefit and Payment Parameters, HHS laid out a protocol for automatic re-enrollment that could be used in circumstances where the enrollee’s insurer stops offering coverage in the exchange. According to Inside Health Policy (trial subscription required), Nebraska is one of at least two states that pushed back against HHS on this issue. Nebraska’s Department of Insurance noted that enrolling people in plans from alternate carriers amounts to selling health insurance without a license, and that state officials will not enroll people in the new plans selected by Healthcare.gov.

Nebraska Department of Insurance administrator for health policy, Martin Swanson, said that the state “reserve[s] the right to investigate any future placement of business by unlicensed entities.” (in this case, “unlicensed entities” refers to the federal government).

BCBSN and UnitedHealthcare’s exit from the Nebraska exchange at the end of 2016 was exactly the sort of scenario where this applies. Under the new HHS protocol for re-enrollment, exchange enrollees who had BCBSN or UnitedHealthcare in 2016 — and who did not return to the exchange by December 15, 2016 to select a new plan for 2017 — were auto-enrolled in a new plan, with priority placed on a plan selection at the same metal level and the same product network type (PPO, HMO, POS, EPO). But if those were not available, there’s a hierarchy that would be used to select what amounts to the most similar plan available.

BCBSN and UnitedHealthcare enrollees were advised to seek out their own replacement coverage during open enrollment. For plan selections made between November 1 and December 15, the new plan took effect January 1, with no gap in coverage. For BCBSN and United enrollees who didn’t return to the exchange to pick a new plan, Healthcare.gov’s protocol was to select a plan on their behalf. And despite the state’s push-back on this issue, automatic re-enrollment was the default for Nebraska exchange enrollees whose plans ended and who didn’t return to the exchange to pick their own plans.

Grandmothered plans

Nebraska’s Department of Insurance allowed pre-2014 plans to be extended in 2014. Following the Obama Administration’s announcement in March that pre-2014 plans could be extended for up to two more years, the Nebraska Department of Insurance decided in late April to allow pre-2014 health insurance plans to be extended out as far as October 2016.

Exchange history in Nebraska

Despite work completed by the Nebraska Department of Insurance (DOI), then-Gov. Dave Heineman announced in November 2012 that the state would not operate a health insurance exchange. In rejecting a state-run exchange, Heineman said it would be much more expensive for the state to run its own exchange. He also expressed doubt that even a state-run exchange would give Nebraska much authority over exchange operations.

Before Heineman’s final decision, he had expressed some support for a state-run exchange, and the DOI had studied that option. The DOI gathered input from stakeholders, developed a set of working assumptions around policy and operations, and issued a number of requests for information and requests for proposals to engage subcontractors in developing an exchange.

While the federal government manages most functions for the new marketplace, Nebraska oversees participating health plans. The Nebraska legislature also authorized a work group, called the Nebraska Exchange Stakeholder Commission, to provide input to state and federal officials on how the marketplace should operate.

In early December, 2014, the Nebraska Exchange Stakeholder Commission announced their recommendation that Nebraska continue to have a federally-run exchange, noting that it would be costly and difficult to switch to a state-run exchange at this point, especially given that federal funding was no longer available to establish a state-run exchange.

Contact the exchange

HealthCare.gov
The federal government operates the exchange in Nebraska

More Nebraska health insurance exchange links

Nebraska Department of Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Nebraska.
(877) 564-7323 / Toll Free: (800) 833-7352

Nebraska DOI’s Listening Sessions for 2019 — a detailed analysis of the history and current state of the individual market in Nebraska, plus a look at alternatives like short-term health plans, association health plans, and health care sharing ministries, from a regulatory standpoint.